Abstract

Introduction

Several guidelines recommend initial empirical treatment with two antibiotics instead
of one to decrease mortality in community-acquired pneumonia (CAP) requiring intensive-care-unit
(ICU) admission. We compared the impact on 60-day mortality of using one or two antibiotics.
We also compared the rates of nosocomial pneumonia and multidrug-resistant bacteria.

Methods

This is an observational cohort study of 956 immunocompetent patients with CAP admitted
to ICUs in France and entered into a prospective database between 1997 and 2010.

Patients with chronic obstructive pulmonary disease were excluded. Multivariate analysis
adjusted for disease severity, gender, and co-morbidities was used to compare the
impact on 60-day mortality of receiving adequate initial antibiotics and of receiving
one versus two initial antibiotics.

Results

Initial adequate antibiotic therapy was significantly associated with better survival
(subdistribution hazard ratio (sHR), 0.63; 95% confidence interval (95% CI), 0.42
to 0.94; P = 0.02); this effect was strongest in patients with Streptococcus pneumonia CAP (sHR, 0.05; 95% CI, 0.005 to 0.46; p = 0.001) or septic shock (sHR: 0.62; 95% CI 0.38 to 1.00; p = 0.05). Dual therapy was associated with a higher frequency of initial adequate
antibiotic therapy. However, no difference in 60-day mortality was found between monotherapy
(β-lactam) and either of the two dual-therapy groups (β-lactam plus macrolide or fluoroquinolone).
The rates of nosocomial pneumonia and multidrug-resistant bacteria were not significantly
different across these three groups.